Provider Demographics
NPI:1558802041
Name:SAMUEL, CHRISTIE
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12360 RICHMOND AVE APT 821
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2450
Mailing Address - Country:US
Mailing Address - Phone:713-518-5575
Mailing Address - Fax:
Practice Address - Street 1:12360 RICHMOND AVE APT 821
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2450
Practice Address - Country:US
Practice Address - Phone:713-518-5575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN/AMedicaid